Provider Demographics
NPI:1427006147
Name:KOOLAU RADIOLOGY, INC
Entity Type:Organization
Organization Name:KOOLAU RADIOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:DE JOURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:808-599-4471
Mailing Address - Street 1:1380 LUSITANA ST
Mailing Address - Street 2:SECOND FLOOR
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96813-2449
Mailing Address - Country:US
Mailing Address - Phone:808-599-4471
Mailing Address - Fax:808-523-3849
Practice Address - Street 1:1380 LUSITANA ST
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2449
Practice Address - Country:US
Practice Address - Phone:808-599-4471
Practice Address - Fax:808-523-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMD025622085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIH53627Medicare ID - Type UnspecifiedMEDICARE GROUP ID